Oncology Monthly Progress Note (MPN) Report

Oncology Monthly Progress Note

This monthly progress note will be used to monitor your ongoing treatment.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Today's Date*

MonthDayYear
Date
Type of Cancer*
Part I: Chief Concern
What is your chief concern?
Copyright © {todaysDate90:year} Dr. Daniel Thomas, Inc.

Dr. Daniel Thomas, DO, MS | Dr. Sylvia Torres-Thomas, Ph.D., APRN, FNP-C

Pain intensity?*

	0	1	2	3	4	5

0 is No hurt, 5 is Hurts Worst

Where is the pain located?
Please enter the relevant numbers from the figure above for the location of your pain (e.g. 14,8,39).
Describe the pain
e.g. Numbness, Stabbing, Burning, Stiffness, Pins and needles, Dull aching, Cramps, etc.
How long have you had this pain?
Hours, days, weeks, etc.
What makes the pain better?
What makes the pain worse?

Part IV: Other Questions, Concerns, Or Needs For Medications Supplied From Our Office
1. Primary question, concern, or need for medication supplied from our office
2. Secondary question, concern, or need for medication supplied from our office
3. Tertiary question, concern, or need for medication supplied from our office

Part V: Recent Lab Results and Scans
Attach a copy of your CBC and CMP, tumor markers (if applicable) results within the last 30-days.

Browse Files
All attachments are properly secured and encrypted to be HIPAA compliant. Cancelof
Attach a copy of imaging or scan results you've done within the past 30-days.

Browse Files
All attachments are properly secured and encrypted to be HIPAA compliant. Cancelof
Patient acknowledges and agrees that Dr. Daniel Thomas and Dr. Sylvia Torres-Thomas, along with their assigns, will be entitled to use any data, discoveries, results, improvements, or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications. The patient acknowledges receiving a copy of the Notice of Privacy Practices and Informed Consent. All data will be kept on a secured and encrypted Cloud-Based system that is password-protected, and only accessible to Healthy And Strong staff.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
Date
Copyright © {todaysDate90:year} Dr. Daniel Thomas, Inc.

Dr. Daniel Thomas, DO, MS | Dr. Sylvia Torres-Thomas, Ph.D., APRN, FNP-C

344 S. Highland St., Mount Dora, FL 32757

Phone: (352) 729-0923

Fax: (888) 481-6799

Email: office@healthyandstrong.com
Should be Empty:

	Name of Prescription Medication	Dosage	Frequency	Refill Needed?
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8
Prescription 9
Prescription 10
Prescription 11
Prescription 12
Prescription 13
Prescription 14
Prescription 15